Nicholas Strasser MD Sports Foot and Ankle Surgeon

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Achilles tendon rehabilitation

The typical Achilles tendon rupture occurs in the mid-substance of the Achilles tendon. This is generally in the weekend warrior, recreational athlete, in his late 20’s to early 40’s. However, it does occur less commonly in the high-level competitive athlete. The optimum treatment for complete Achilles tendon ruptures remains controversial. The following guidelines are for a surgical repair, not non-operative treatment of acute Achilles tendon ruptures. The acute repair consists of using suture material to re-approximate the ends of the tendon and restore appropriate length-tension relationships of the gastroc soleus complex.  This could be with a traditional open approach or could be a Minimally Invasive Technique (MIS).  

Due to variation in surgical techniques several time frames may be adjusted.  Check with your individual surgeons’ guidelines.

 

Big Picture –
  • 0 to 2 weeks: non weight bearing in a splint
  • 2-4 weeks: transition to a postoperative boot – remain nwb until 4 weeks
  • 6 weeks: begin weaning heel lifts/
  • 4-8 weeks: progressive WB protocol
  • 8-12 weeks: transition from boot to shoes – biggest risk for re-tear is between 8-12 weeks!

First Postoperative Visit:

 2 Weeks postoperatively:

  1. The patient’s wound is evaluated and the sutures should not be removed unless the wound is completely dry and healed.
  2. Once the sutures are removed the patient can then follow-up with the protocol dictated be the physician in his operative report. A walking boot will be placed which will remain in use full time until 8 weeks after surgery.
  3. You can begin gentle ankle range of motion below a right angle or 0 degrees of flexion. (not to exceed neutral dorsiflexion)
  4. Continue NWB until 4 weeks postoperatively then begin a progressive increase in weight-bearing.
  5. Begin Physical Therapy (PT) –

Second Postoperative Visit:

6 Weeks postop:

  1. Boot removed and wound re-evaluated.
  2. Gradually begin removing heel lifts or moving boot from 30 degrees of plantarflexion to 0 degrees.

Physical Therapy:

“General” tissue healing times:

  • Immobilization to protect the repair, 4 weeks after surgery
  • A/AROM: 4 weeks postop, based on pain, swelling, and tissue quality of repair.
  • AROM: 4-6 weeks s/p, based on pain, swelling, and tissue quality of repair.
  • Resistive ROM: 8-10 weeks postop, based on pain, swelling, and tissue quality of repair.
  • Progress as tolerated: 12 weeks postop, based on pain, swelling, and tissue quality of repair.

PHASE 1:

Weeks 0-3 Postop:

Goals:

  • Promote skin healing
  • Minimize swelling and pain
  • Protect repaired tendon
  • Postop protocol:
  • Sutures typically removed 2-3 weeks after surgery and transitioned to postop boot in plantarflexion
  • Prescription for PT given to begin after splint removal

PHASE 2:

3-6 Weeks Post-Op:

Goals:    

  • Complete protection of repair.
  • Look to have neutral dorsiflexion between 6-8 weeks after surgery.
  • Progressive edema reduction, pain control, desensitization and scar mobility.
  1. Progress from PWB to FWB with crutches/cane between weeks 6-8 based on pain, swelling and tissue quality of repair.
  2. Short leg brace/orthosis worn during FWB ambulation. (until 8 weeks after surgery)
  3. Limit active dorsiflexion ROM to neutral with knee flexed to 90 for first four weeks.
  4. No passive stretching into dorsiflexion until 8 weeks s/p.
  5. Bicycle; light resistance, with brace on until 8 weeks after surgery, then progress as appropriate.
  6. Proximal musculature PRE’s as tolerated, no closed chain Dorsiflexion past neutral until 8 weeks s/p.
  7. Modalities for edema reduction, pain control, desensitization and scar mobility.

PHASE 3

6-10 Weeks Post-op:

 

Goals:    

  • Restoration of normal walking gait
  • Elimination of edema, pain, normalize sensitivity and normalize scar mobility.
  • Improved 4-Quadrant ROM
  1. Static balance progression and proprioceptive training (6 weeks).
  2. Bicycle, increase resistance as tolerated (8 weeks).
  3. Inversion and eversion isometrics.
  4. Low resistance isotonics, through a pain-free ROM.
  5. Gentle passive dorsiflexion beginning at 8 weeks.
  6. Modalities PRN.
  7. Remove heel lifts or adjust boot plantarflexion toward a right angle.
  8. 8 weeks discontinue boot and initiate heel lift in regular shoe, as per Dr.’s recommendations.
  9. Dynamic balance progression and proprioceptive training (8-10weeks) based on pain, swelling and tissue quality of repair.

PHASE 4

10-14 Weeks Post-op:

 

Goals:    

  • Improve strength.
  • Restore normal A/PROM.
  • Increase intensity of Cardio activity
  1. Progressive plantar and dorsiflexion PRE’s as tolerated, emphasize plantar flexion eccentrics.
  2. Inversion/eversion PRE’s as tolerated.
  3. Plantar and Dorsiflexion Isokinetics as appropriate.
  4. Continue proximal musculature PRE’s.
  5. Reassess entire LE Biomechanics identifying areas that would increase long-term stress to the reconstruction.
  6. Begin double limb heel raise (week 12)
  7. Progression to walk/jog program (12 weeks) if appropriate strength and function. (Minimum 15-20 single leg toe raises)

PHASE 5:

14-24 Weeks Post-op:

Goals:

  • As Above
  • Continue lower extremity strength training
  • Add agility and sport specific activity

Progressive return to athletic activities (16 weeks): if all above goals are achieved.

 

  1. Continue functional closed chain rehabilitation.
  2. Advanced proprioceptive retraining, Fitter, BAPS, Plyoback, Agility drills, etc.
  3. Continue full LE PRE’s.
  4. Progressive running program. Isokinetic testing.
  5. Sports Performance and Speed and Agility Drills/Testing.

PHASE 6:

24-52 Weeks Postop:

 

Goals:

  • As above
  • Sport Specific Activity
  • Prevent Injury –

Progressive back to Sports Specific Activity:

  • Motion should be pain free and symmetric
  • Equal strength between both limbs
  • Symmetry of gait with running, jumping, cutting and pivoting
  • Monitor for symmetric ROM with sport specific activities as the athlete fatigues

After Return to Sport:

  • Total body strengthening exercise
  • Single leg (for both limbs) eccentric Achilles training

Works Cited:

1)  Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75. doi: 10.2106/JBJS.I.01401. Epub 2010 Oct 29. PMID: 21037028.

2)  Orthopaedic Rehabilitation of the Athlete, 1st Edition,Getting Back in the Game  Authors : Bruce Reider & George Davies & Matthew T Provencher